New York Headache Center

Treating migraines in adolescents presents some unique challenges.  Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks.  And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers.  The problem has been proving to the FDA that these drugs work in kids.  Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo.  Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks).   Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents.  A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age.  The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches.  I am often asked by other physicians, what is the youngest age I would prescribe a triptan?  Because of a shortage of pediatric neurologists I feel compelled to see children as young as 10 and this is the youngest age at which I will prescribe triptans.

For many years headaches were thought to be triggered by elevated blood pressure.  Evidence had suggested that only very sudden increase in blood pressure triggered a headache in some patients, but the myth of high blood pressure headaches has persisted.  Norwegian researchers published a very surprising finding in the April issue of journal Neurology.   They looked at the data on 120,000 people and found that increasing systolic blood pressure was associated with a decrease in migraine and non-migraine headaches.  Even more striking was the inverse correlation with the pulse pressure (difference between systolic and diastolic pressure, for example blood pressure of 110/80 means that the pulse pressure is 30).  Patients with higher pulse pressure had fewer migraine and other headaches.  It can be speculated that hardening of arteries that occurs with elevated blood pressure makes them less likely to constrict and dilate, which is part of a migraine process.

Menstrual migraines are at times very difficult to treat.  Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief.  Corticosteroid drugs, such as prednisone and dexamethasone can help some patients.  Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two.  Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women.  We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried.  Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects.

Scientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches.  They hypothesized that combining two different approaches would yield better outcomes than either one alone.  A neurotransmitter CGRP antagonists appear to be effective in the treatment of an acute migraine.  Merck has a product in late stages of development that works through this mechanism and hopefully will be the first of a new class of migraine drugs.  Based on laboratory research the Italian group suggests that combining a CGRP antagonist with a blocker of nerve growth factor may result in a more effective treatment.  This fits with a new trend in treatment of many conditions - combining drugs that work in different ways, rather than trying to always use a single medication.

Treatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment, but because of a communication barrier.  Doctors appear not to want to hear what migraine patients have to say about their headaches, according to a remarkable study by a top headache researcher Richard Lipton and his colleagues.  Patients and doctors agreed to be videotaped during a visit and 60 such interactions were analyzed.  The analysis showed that doctors did not ask about the disability of headaches and tended to ask closed-end short questions.  Very often the information they did obtain was incorrect.  55% of doctor-patient pairs were misaligned regarding frequency of attacks; 51% on the degree of impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.  The authors recommended that doctors assess impairment using open-ended questions in combination with what is called the ask-tell-ask technique.  

How long will I suffer from migraines?  Will it ever go away?  These are very common questions patients ask their doctors.  Drs. Bigal and Lipton reviewed a recent large study that looked at what happens to migraine patients within one year of observation.  The study found that migraine completely went away in 10%, improved in 3% and worsened and became chronic (occurring on more than 15 days each month) in 3%.  This confirms what we’ve know all along – migraine headaches tend to go away with age.  In women this often happens after menopause and in men at around similar age; however this study and our experience indicates that for many people migraines may go away earlier, at any point in their lives.  The problem is that we can never predict when this will happen and in a small percentage of patients (about 3%) migraines never go away.